Policies and information: Basic Policies: Please be on time for your appointments. If you are late for your scheduled appointment, there is a chance that you will be rescheduled. We require at least 24 hours notice to cancel appointments. If you miss two consecutive appointments you will be required to prepay your next appointment in order to reschedule. If you miss a third appointment you will be discharged from the practice. These rules are subject to change at the provider s discretion. Failure to show for appointments without prior notification may result in fees. Patients under the age of 18 require a parent or guardian that can legally give consent for treatment for the minor patient to be present at all appointments. Payment for services is due in full at the time the service is provided in our office. In the event that a pathology specimen is sent out for processing, you will receive bills for these services from an outside agency. The majority of these are sent to University of Utah Health Care (800-245-0357). Please contact that agency with questions regarding billing, etc. You should inquire with your insurance company for particular coverage at this facility. Financial Policies: Insurance Coverage We will bill most insurance carriers if proper identification is provided to us. Insurance cards must be present along with a valid picture ID in order for us to bill your insurance for you. Copayments are due at the time of service. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for your care. If an insurance carrier has not paid within 60 days of billing, professional fees are due and payable in full from you. Communicating changes to your insurance is your responsibility If you fail to communicate changes in insurance, you may be responsible for paying your medical bill out of pocket. Surgery Fees All co-pays, deductibles, and payments for non-covered surgical procedures are due prior to your surgery. Prior authorization may be required by your carrier and this is your responsibility to obtain this prior to your procedure. Non-covered Services Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notice of insurance claim denial. NSF Checks (Checks that are returned by the bank unpaid) There will be a fee of $35.00 added to the account balance in the event that a check is returned unpaid.
Balances Sent to Collections In the event your account has a balance after all attempts have been made to collect said balance, your account will be forwarded to an outside collection agency. If your account is sent to collection, you are responsible for all amounts due plus costs of collection including: Handling charge up to fifty percent (50%) of your account balance if it must be sent to collection. All collection expenses charged by the collection agency. Court costs and attorneys fees. Patients that have been sent to collections will be discharged from the clinic. Personal Injury Cases This office does not bill for auto accident or other liability or lawsuit-related cases. You are responsible for payment in full at the time of service. We do not accept liens. Release of Information I authorize Montrose Dermatology to release to my insurance carrier(s) and/or CMS and its agents and/or my secondary insurer any information needed to determine benefits or benefits payable for related services. I hereby authorize health providers at Montrose Dermatology to release any information regarding services rendered by him/her and allow a photocopy of my signature to be used to file insurance. I hereby authorize and direct my insurer to issue payment check(s) for benefits due me for the services rendered by any providers affiliated with Montrose Dermatology. Regardless of my insurance benefits, if any, I understand I am financially responsible for the fees for services rendered. I have read and agree to the Financial Policy and Release of Information paragraphs stated above that apply to me. Patient or Responsible Party signature Date Printed Name of Patient or Responsible Party DOB of Patient Relationship to Patient Phone
Patient Registration Form First Name: Middle Initial: Last Name: Address: City, State: Home Phone: Best Number to leave an Appointment Reminder call: Home Email: Zip Code: Cell Phone: Cell SSN: Date of birth: Age: Sex: M F Married Single Divorced Widow Employed by: Work Phone #: Address: City, State: Zip Code: Parent/Guardian name for Minors (under the age of 18): SSN: Billing Address: Date of birth: Others we may share your health information with (such as biopsy results, etc): Name of Primary Physician: Address (if known): City, State: Zip Code: Office Phone#: How did you learn about our practice?
Insurance Information: Are you the holder of the medical insurance card policy? YES NO (If NO, please complete below) Name of Policy Holder: Relationship to Patient: Policy Holder s Date of Birth: Policy Holder s SSN: Our office will file insurance for all reimbursable services, to both your primary and secondary insurance carriers. Please remember that you are responsible for all deductible, co-pay, and non-covered service amounts. See our complete financial policy for details. I authorize the release of any medical information necessary to process my claim. I authorize payment of medical and surgical benefits to Renata Raziano, MD. ***Workers Compensation Information (If applicable):*** Did your injury happen on the job? Yes No If yes, on what date did the injury occur? Did you report the accident to your employer? Yes No It is your responsibility to make sure you have verified authorization with your case manager to see a specialist prior to your appointment. Workers compensation does not usually allow for self referrals.
Receipt of Notice of Privacy Practices Written Acknowledgement Form I am a patient of Montrose Dermatology. I hereby acknowledge receipt of Montrose Dermatology s Notice of Privacy Practices. Signature: Print Name: OR I am a parent or legal guardian of [patient name]. I hereby acknowledge receipt of Montrose Dermatology s Notice of Privacy Practices with respect to the patient. Signature: Relationship to Patient: Parent Legal Guardian Print Name: